Background: Jaundice and hyperbilirubinemia are common conditions in neonates. Prolonged direct hyperbilirubinemia/cholestasis is less common. Biliary atresia, a primary cause of cholestasis in infancy, is a rare condition in the NICU compared to total parenteral nutrition (TPN) related cholestasis. A hepatobiliary scintigraphy with imindiacetic acid (HIDA) scan may be performed as part of the evaluation for cholestasis. HIDA scans have high sensitivity but variable specificity. There is little data on HIDA scans in preterm infants. Objective: To describe a series of infants in the NICU, < 37 weeks gestation who had a HIDA scan performed as part of an evaluation for cholestasis Methods: This was a retrospective, IRB approved, case series of infants in the NICU who had a HIDA scan prior to discharge. Cases were identified by querying HIDA scans performed between 7/1/2015 and 9/30/2016 at Rainbow Babies and Children’s Hospital in Cleveland, OH. The variables collected include: gestational age (GA), birth weight (BW), HIDA scan results, liver biopsy, early and late onset sepsis, congenital anomalies, NPO days, duration of TPN use, peak total and direct bilirubin, necrotizing enterocolitis (NEC), GI surgery, abdominal ultrasounds, and state newborn screen results. Results: We identified 6 cases in which a HIDA scan was performed over a 15 month period. GA ranged from 27-35 weeks. Five cases were < 30 weeks gestation. One infant, born at 35 weeks gestation, was excluded from analysis due to the diagnosis of gastroschisis, a known significant risk factor for cholestasis. In the 5 remaining patients, the median number of days of TPN use was 35 and HIDA scans were completed at a median age of 61 days of life. Four of the infants had inconclusive HIDA scan results. One infant developed hypothermia during the study. Three infants with inconclusive HIDA scans had liver biopsies demonstrating TPN hepatitis. No infant was diagnosed with BA by HIDA scan or liver biopsy. Conclusions: In our series of TPN exposed very to extremely preterm infants with cholestasis, HIDA scans were largely inconclusive. Furthermore, due to inconclusive results, a liver biopsy was performed in the majority of cases. Both HIDA scans and liver biopsies may pose significant risks to this patient population. Cost and value-based care are also important considerations. It may be prudent to consider eliminating the use of HIDA scans in the evaluation of cholestasis in preterm infants in the NICU at risk for TPN cholestasis.

Cases

GA: gestational age, BW: birth weight, SGA: small for gestational age, EOS: early onset sepsis, LOS: late onset sepsis, SIP: spontaneous intestinal perforation, DOL: day of life

Cases

GA: gestational age, BW: birth weight, SGA: small for gestational age, EOS: early onset sepsis, LOS: late onset sepsis, SIP: spontaneous intestinal perforation, DOL: day of life

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